Management Algorithms for Diabetic Macular Edema

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29 Οκτ 2013 (πριν από 3 χρόνια και 8 μήνες)

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RETINOPATHY
NOVEMBER/DECEMBER 2005 I DIABETIC MICROVASCULAR COMPLICATIONS TODAY I 31
I
t is possible to devise a relatively simple checklist to
facilitate the management of diabetic macular edema
(DME), according to Julia A. Haller, MD. Dr. Haller, the
Katharine Graham professor of ophthalmology at The
Wilmer Eye Institute, Johns Hopkins School of Medicine,
spoke at the American Academy of Ophthalmology 2005
Retina Subspecialty Day in Chicago.
Dr. Haller said that the first thing physicians must do when
treating DME patients is evaluate the patients’ medical con-
trol of their diabetic condition. Specifically, this means check-
ing HbA1c, blood pressure and lipid levels. She said that if
these parameters are not within the normal range, then
patients should be referred for further management to
improve the condition.
COMPLETE OCULAR EVALUATI ON
The next step is to perform a complete ocular evaluation.
This includes assessment of lens opacity, glaucoma status
and other eye findings, in addition to retinal examination, Dr.
Haller said. Retinal examinationincludes evaluation of the
macula. Tests to perform include fundoscopy and contact
lens biomicroscopy. Ophthalmologists may want to consider
fluorescein angiography and optical coherence tomography
as well, she added.
A thorough evaluation of the level of retinopathy should
be performed as well, also using fundoscopy and contact
lens biomicroscopy. Dr. Haller said that photographs might
be needed as well as fluorescein angiography to evaluate per-
fusion and echography if media opacity is compromised.
Treatable causes of macular edema other than diabetic
vascular leakage alone should be ruled out. This includes, for
example, Irvine-Gass syndrome or vitreomacular traction.
Dr. Haller said that if the patient’s condition is medically
out of control, the first part of treatment may be medical
management. Other causes of macular edema should be
treated if possible. If a clinical evaluation shows that the
patient has definite vitreomacular traction, for example, then
vitrectomy may be an option.
If there is no vitreomacular traction and yet the patient’s
condition is medically under control, then the first line of
therapy remains focal Early Treatment Diabetic Retinopathy
Study-type photocoagulation, Dr. Haller said. “The Diabetic
Retinopathy Clinical Research Network [DRCR.net] proto-
cols have standardized widely accepted current parameters
used for this type of treatment,” she said (Table 1). See story
on page 29 for more information on DRCR.net.
Also regarding initial treatment options, other considera-
tions include level of retinopathy and whether panretinal
photocoagulation will be required immediately or in the
near future.
FOLLOW-UP AND FURTHER TREATMENT
If macular edema resolves with post laser follow-up at
3 months and if retinopathy level does not require panretinal
photocoagulation, Dr. Haller said to continue to follow the
patients. If macular edema persists but improves, and there is
no need for panretinal photocoagulation, continued follow-
up may be considered rather than additional focal photocag-
ulation.
The third scenario, persistent or worsening macular
edema, calls for a consideration of all possible factors. This
includes medical status, checking for evidence of vitreomac-
ular traction and evaluation for epiretinal membrane. If
nothing significant is found, then standard therapy would
call for further focal laser photocoagulation, Dr. Haller said.
What if macular edema still fails to resolve? Additional
options include further laser. However, Dr. Haller said at
some point the question has to be asked, when is it appro-
Management
Algorithms for Diabetic
Macular Edema
Physicians should always consider referring patients for inclusion
in appropriate clinical trials.
BY CONNI BERGMANN KOURY, EDITOR-IN-CHIEF
priate to stop performing laser treatments? At this point
we also may consider other available options. Further
approaches include off-label treatment with available drugs
including steroids such as intravitreal, subtenon’s or
peribulbar triamcinolone or intravitreal fluocinolone ace-
tonide (Retisert, Bausch & Lomb), pegaptanib (Macugen,
EyeTech/Pfizer) or bevacizumab (Avastin, Genetech). There
are drawbacks to this approach, including possible develop-
ment of cataract, glaucoma and unknown long-term side
effects, particularly with repeated dosings.
Vitrectomy has been used as a treatment for unrespon-
sive macular edema with or without evidence of vitreo-
macular traction or no matter the condition of the
epiretinal membrane, with or without concomitant inter-
nal limiting membrane peeling, steroid and laser treat-
ment. There is a lack of prospective information on these
approaches, however, and their role in this disease
remained to be elucidated.
Dr. Haller urged physicians to consider referring appro-
priate patients for enrollment in clinical trials. Possibilities
include the DRCR.net, which is studying intravitreal triam-
cinolone versus focal laser as well as peribulbar triamci-
nolone and vitrectomy. Other investigations are Allergan’s
Posurdex trial of intravitreal dexamethasone sustained
delivery device, Macugen and Lucentis for DME, Eli Lilly
and Company’s ongoing studies of ruboxistaurin, a pro-
tein kinase C-beta inhibitor, among others.
“By carefully sorting through the potential therapies and
combinations of therapies we will be able to construct
intelligent algorithms to responsibly advise our diabetic
patients.”

Julia A. Haller, MD, is the Katharine Graham Professor of
Ophthalmology at Wilmer Eye Institute, Johns Hopkins
University, 600 North Wolfe Street Maumenee 740 Baltimore,
MD 21287-9277. She can be reached at 410-955-4714; fax:
410-614-7632; or e-mail: jhaller@jhmi.edu.
Haller JA. Management algorithms for diabetic macular edema. Presented at the American
Academy of Ophthalmology 2005 Annual Meeting. Retina Subspecialty Day. October 14-18,
2005.
Burn Characteristic Focal/Grid Photocogulation (modified ETDRS technique)
Area considered for treatment 500 to 300 microns from the center of the macula. No burns are placed
within 500 microns of the optic disk
Wavelength Green-to-yellow wavelengths
Burn size 50 microns
Burn duration 0.05 to 0.1 seconds
Grid treatment If fluorescein angiography is performed, apply to all areas of diffuse leakage
or nonperfusion within the area outlined above
Burn intensity Barely visible (light grey)
Burn separation Two visible burn widths apart
Focally treat leaking microaneurysm All leaking microaneurysms are focally treated, but only in areas of retinal
thickening located within treatment area outlined above
Change microaneurysm color Not required, but at least a mild burn should be evident beneath all
microaneurysms
Note: The investigator may choose any laser wavelength for photocoagulation within the green-to-yellow spectrum. The wave-
length used will be recorded and any retreatment must use the same wavelength. Lenses used for laser retreatment cannot
increase or reduce the burn size by >10%.
32 I DIABETIC MICROVASCULAR COMPLICATIONS TODAY I NOVEMBER/DECEMBER 2005
RETINOPATHY
TABLE 1. PHOTOCOAGULATION TREATMENT FROM DRCR.NET